Healthcare Provider Details

I. General information

NPI: 1750650933
Provider Name (Legal Business Name): CREATIVE BEHAVIOR INTERVENTIONS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2011
Last Update Date: 12/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3002 DOW AVE SUITE 520
TUSTIN CA
92780-7233
US

IV. Provider business mailing address

3002 DOW AVE SUITE 520
TUSTIN CA
92780-7233
US

V. Phone/Fax

Practice location:
  • Phone: 949-861-1580
  • Fax: 949-328-7689
Mailing address:
  • Phone: 949-861-1580
  • Fax: 949-328-7689

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-07-3777
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License NumberPSY22024
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number1-07-3777
License Number StateCA

VIII. Authorized Official

Name: DR. DENISE MARIE ECKMAN
Title or Position: PRESIDENT
Credential: PSY.D., BCBA-D
Phone: 949-861-1580